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Nursing Health Assessment A Best Practice Approach 3rd Edition Jensen
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Test Bank For Nursing Health Assessment A Best PracticeApproach 3rd Edition Jensen | 9781496349170 | All Chapters
with Answers and Rationals
Assessment - ANSWER: Collection of subjective and objective data
Diagnoses - ANSWER: Analysis of subjective and objective data to make a professional nursing
judgement
Planning - ANSWER: Developing a plan of nursing care and outcome criteria
Implementation - ANSWER: Carrying out the plan of care
Evaluation - ANSWER: Assessing whether outcome criteria have been met and revising the plan of
care if necessary
Nursing Diagnosis - ANSWER: Clinical judgement about individual, family or community responses to
actual or potential health problems and life processes
Subjective Data - ANSWER: Sensations or symptoms that can be verified only by the client (ex. pain)
Objective Data - ANSWER: Findings directly observed or indirectly observed through measurements
(ex. body temperature)
Collaborative Problem - ANSWER: Physiologic complications that nurses monitor to detect their onset
or changes in status
Referral Problem - ANSWER: Problem that requires the attention or assistance of other health care
professionals
A medical examination differs from a comprehensive nursing examination in that the medical
examination focuses primarily on the client's - ANSWER: Physiologic status
The result of a nursing assessment is the - ANSWER: Formulation of nursing diagnoses
Although the assessment phase of the nursing process precedes the other phases, the assessment
phase is - ANSWER: Continuous
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an
assessment termed - ANSWER: Comprehensive
An ongoing or partial assessment of a client - ANSWER: Includes a brief reassessment of the client's
normal body system
The purpose of the comprehensive health assessment is to - ANSWER: Arrive at conclusions about the
client's health
The use of this type of question can keep a client interview from going off track - ANSWER: Closed-
ended
A nurse can clarify a client's statements by - ANSWER: Rephrasing the client's statements
During what phase of the interview between a nurse and client do you collaborate to identify
problems and goals - ANSWER: Working phase
, When dealing with a manipulative client it is important for the nurse to - ANSWER: Provide structure
and set limits
The primary purpose of the health history is to - ANSWER: Identify risk factors to the client and his or
her significant others
Define the "COLDSPAA" accronym - ANSWER: Character, Onset, Location, Duration, Severity, Pattern,
Associated factors, how it Affects the client
Sim's position - ANSWER: Side-lying position used during the rectal examination
Sitting Position - ANSWER: Position used during much of the physical examination including
examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper
extremities
Supine Position - ANSWER: Back-lying position used for examination of the abdomen (with one small
pillow under the head and another under the knees); this position also allows easy access for
palpation of peripheral pulses
Standing Position - ANSWER: Position used to examine male genitalia and to assess gait, posture, and
balance
Prone Position - ANSWER: Client lies on abdomen with head turned to the side; may be used to assess
back and mobility of hip joint
Lithotomy Position - ANSWER: Back-lying position with hips at edge of examining table and feet
supported in stirrups; used for examination of female genitalia, reproductive tract, and rectum
What part of the examiner's hand is used to feel for fine discriminations: pulses, texture, size,
consistency, shape, and crepitus - ANSWER: Fingerpads
Part of the examiner's hand used to feel for vibration, thrills, or fremitus - ANSWER: Ulnar surface or
palm of hand
Part of the examiner's hand used to feel for temperature - ANSWER: Dorsal surface of hand
Smaller end of stethoscope used to detect low-pitched sounds (abnormal heart sounds and bruits) -
ANSWER: Bell of stethoscope
Larger end of stethoscope used to detect breath sounds, normal heart sounds, and bowel sounds -
ANSWER: Diaphragm of stethoscope
Name the four basic techniques used for physical assessment - ANSWER: Inspection, palpation,
percussion, auscultation
Name the five steps of the nursing process - ANSWER: Assessment, diagnosis, planning,
implementation and evaluation
What are the four sections of the nursing assessment framework? - ANSWER: History of present
health concern, past health history, family history and lifestyle and health practices
What are the four basic types of assessments? - ANSWER: Initial comprehensive assessment, ongoing
or partial assessment, focused or problem oriented assessment and emergency assessment
Name the four major steps of the assessment phase - ANSWER: Collection of subjective data,
collection of objective data, validation of data and documentation data
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